How, when and why to establish preoperative surgical risk in thoracic surgery.

PURPOSE OF REVIEW: Emphasizing a systems-based approach, we discuss the timing for referral for perioperative surgical consultation. This review then highlights several types of comorbidities that may complicate thoracic procedures, and references recent best practices for their management. RECENT FINDINGS: Patients requiring thoracic surgeries present some of the most challenging cases for both intraoperative and postoperative management. The recent SARS-CoV-2 pandemic has only exacerbated these concerns. Effective preoperative optimization, however, provides for identification of patient comorbidities, allowing for mitigation of surgical risks. This kind of planning is multidisciplinary by nature. We believe patients benefit from early engagement of a dedicated preoperative clinic experienced for caring for complex surgical patients. SUMMARY: Optimizing patients for thoracic surgery can be challenging for small and large health systems alike. Implementation of evidence-based guidelines can improve care and mitigate risk. As surgical techniques evolve, future research is needed to ensure that perioperative care continues to progress.

Quantitative Neuromuscular Monitoring in Clinical Practice: A Professional Practice Change Initiative.

BACKGROUND: Residual neuromuscular blockade can be avoided with quantitative neuromuscular monitoring. The authors embarked on a professional practice initiative to attain documented train-of-four ratios greater than or equal to 0.90 in all patients for improved patient outcomes through reducing residual paralysis. METHODS: The authors utilized equipment trials, educational videos, quantitative monitors in all anesthetizing locations, and electronic clinical decision support with real-time alerts, and initiated an ongoing professional practice metric. This was a retrospective assessment (2016 to 2020) of train-of-four ratios greater than or equal to 0.9 that were documented before extubation. Anesthesia records were manually reviewed for neuromuscular blockade management details. Medical charts of surgical patients who received a neuromuscular blocking drug were electronically searched for patient characteristics and outcomes. RESULTS: From pre- to postimplementation, more patients were assigned American Society of Anesthesiologists Physical Status III to V, fewer were inpatients, the rocuronium average dose was higher, and more patients had a prereversal train-of-four count less than 4. Manually reviewed anesthesia records (n = 2,807) had 2 of 172 (1%) cases with documentation of train-of-four ratios greater than or equal to 0.90 in November 2016, which was fewer than the cases in December 2020 (250 of 269 [93%]). Postimplementation (February 1, 2020, to December 31, 2020), sugammadex (650 of 935 [70%]), neostigmine (195 of 935 [21%]), and no reversal (90 of 935 [10%]) were used to attain train-of-four ratios greater than or equal to 0.90 in 856 of 935 (92%) of patients. In the electronically searched medical charts (n = 20,181), postimplementation inpatients had shorter postanesthesia care unit lengths of stay (7% difference; median [in min] [25th, 75th interquartile range], 73 [55, 102] to 68 [49, 95]; P < 0.001), pulmonary complications were less (43% difference; 94 of 4,138 [2.3%] to 23 of 1,817 [1.3%]; P = 0.010; -1.0% difference [95% CI, -1.7 to -0.3%]), and hospital length of stay was shorter (median [in days] [25th, 75th], 3 [2, 5] to 2 [1, 4]; P < 0.001). CONCLUSIONS: In this professional practice initiative, documentation of train-of-four ratios greater than or equal to 0.90 occurred for 93% of patients in a busy clinical practice. Return-of-strength documentation is an intermediate outcome, and only one of many factors contributing to patient outcomes.

Contrast-enhanced paravertebrogram to confirm paravertebral catheter position in elective thoracic surgery: a proof of concept study.

BACKGROUND: Paravertebral pain catheters have been shown to be equally effective as epidural pain catheters for postoperative analgesia after thoracic surgery with the possible additional benefit of less hemodynamic effect. However, a methodology for verifying correct paravertebral catheter placement has not been tested or objectively confirmed in previous studies. The aim of the current study was to describe a technique to confirm the correct position of a paravertebral pain catheter using a contrast-enhanced paravertebrogram. METHODS: A retrospective cohort proof of concept study was performed including 10 consecutive patients undergoing elective thoracic surgery with radiographic contrast-enhanced confirmation of intraoperative paravertebral catheter placement (paravertebrogram). RESULTS: The results of the paravertebrograms, which were done in the operating room at the end of the procedure, verified correct paravertebral catheter placement in 10 of 10 patients. The radiographs documented dissemination of local anesthetic within the paravertebral space. CONCLUSION: This proof of concept study demonstrated that a contrast-enhanced paravertebrogram could be used in conjunction with standard postoperative chest radiography to add valuable information for the assessment of paravertebral catheter placement. This technique has the potential to increase the accuracy and efficiency of postoperative analgesia, and to set a quality standard for future studies of paravertebral pain catheters.

Apophenia and anesthesia: how we sometimes change our practice prematurely.

Human beings are predisposed to identifying false patterns in statistical noise, a likely survival advantage during our evolutionary development. Moreover, humans seem to prefer "positive" results over "negative" ones. These two cognitive features lay a framework for premature adoption of falsely positive studies. Added to this predisposition is the tendency of journals to "overbid" for exciting or newsworthy manuscripts, incentives in both the academic and publishing industries that value change over truth and scientific rigour, and a growing dependence on complex statistical techniques that some reviewers do not understand. The purpose of this article is to describe the underlying causes of premature adoption and provide recommendations that may improve the quality of published science.

RéSUMé: Les êtres humains ont tendance à identifier de fausses corrélations dans le bruit de fond statistique, ce qui nous a probablement conféré un avantage en matière de survie au cours de notre développement évolutionnaire. De plus, l'être humain semble préférer les résultats « positifs ¼ aux résultats « négatifs ¼. Ces deux caractéristiques cognitives posent un cadre expliquant l'adoption hâtive d'études faussement positives. À cette prédisposition s'ajoutent la tendance des revues à « surenchérir ¼ pour les manuscrits prometteurs ou notables, les incitatifs tant dans les milieux académiques qu'éditoriaux, qui préfèrent le changement à la vérité et à la rigueur scientifique, et une dépendance croissante à l'égard de techniques statistiques complexes que certains réviseurs ne comprennent pas. L'objectif de cet article est de décrire les causes sous-jacentes d'adoption prématurée de nouveautés et de proposer des recommandations afin d'améliorer la qualité de la science publiée.

Continuous Transversus Abdominis Plane Block for Primary Open Inguinal Hernia Repair: A Randomized, Double-Blind, Placebo-Controlled Trial.

OBJECTIVE: Patients undergoing open inguinal hernia repair may experience moderate to severe postoperative pain. We assessed opioid consumption in subjects who received a continuous transversus abdominis plane block in addition to standard multimodal analgesia. DESIGN: Randomized, double-blind, placebo-controlled. SETTING: Tertiary academic medical center. SUBJECTS: Adult patients undergoing open inguinal hernia repair at Virginia Mason Medical Center. A total of 90 patients were enrolled. METHODS: Subjects presenting for surgery were randomized to receive either a continuous transversus abdominis plane block or a subcutaneous sham block. The primary outcome was opioid consumption within the first 48 hours after surgery. Secondary outcomes included pain scores, activities assessment scores, and opioid-related adverse events. Multimodal analgesia utilized in both groups included acetaminophen, nonsteroidal anti-inflammatory drugs, and surgical local anesthetic infiltration. RESULTS: Eighty-two subjects, 42 from the block group and 40 from the sham group, completed the study, per protocol. The intention-to-treat analysis demonstrated no difference in 48-hour postoperative oxycodone equivalent consumption between the block and sham groups (27.8 mg ± 26.8 vs 32 mg ± 39.2, difference -4.4 mg, P = 0.55). There was a statistically significant reduction in pain scores at 24 hours in the block group. There were no other differences in secondary outcomes. CONCLUSIONS: Continuous transversus abdominis plane blocks provide modest improvements in pain after open inguinal hernia repair but fail to significantly reduce opioid consumption or improve functional activity levels in the setting of multimodal analgesia use.

Comparison of Anterior Suprascapular, Supraclavicular, and Interscalene Nerve Block Approaches for Major Outpatient Arthroscopic Shoulder Surgery: A Randomized, Double-blind, Noninferiority Trial.

BACKGROUND: The interscalene nerve block provides analgesia for shoulder surgery, but is associated with diaphragm paralysis. One solution may be performing brachial plexus blocks more distally. This noninferiority study evaluated analgesia for blocks at the supraclavicular and anterior suprascapular levels, comparing them individually to the interscalene approach. METHODS: One hundred-eighty-nine subjects undergoing arthroscopic shoulder surgery were recruited to this double-blind trial and randomized to interscalene, supraclavicular, or anterior suprascapular block using 15 ml, 0.5% ropivacaine. The primary outcome was numeric rating scale pain scores analyzed using noninferiority testing. The predefined noninferiority margin was one point on the 11-point pain scale. Secondary outcomes included opioid consumption and pulmonary assessments. RESULTS: All subjects completed the study through the primary outcome analysis. Mean pain after surgery was: interscalene = 1.9 (95% CI, 1.3 to 2.5), supraclavicular = 2.3 (1.7 to 2.9), suprascapular = 2.0 (1.4 to 2.6). The primary outcome, mean pain score difference of supraclavicular-interscalene was 0.4 (-0.4 to 1.2; P = 0.088 for noninferiority) and of suprascapular-interscalene was 0.1 (-0.7 to 0.9; P = 0.012 for noninferiority). Secondary outcomes showed similar opioid consumption with better preservation of vital capacity in the anterior suprascapular group (90% baseline [P < 0.001]) and the supraclavicular group (76% [P = 0.002]) when compared to the interscalene group (67%). CONCLUSIONS: The anterior suprascapular block, but not the supraclavicular, provides noninferior analgesia compared to the interscalene approach for major arthroscopic shoulder surgery. Pulmonary function is best preserved with the anterior suprascapular nerve block.

The Effect of Fixation Technique on Continuous Interscalene Nerve Block Catheter Success: A Randomized, Double-Blind Trial.

BACKGROUND: Continuous peripheral nerve blocks offer advantages over single-injection blocks, including extended analgesia and reduction in opioid consumption. These benefits require that the perineural catheter remain intact for the duration of the planned local anesthetic infusion. Mechanical displacement of catheters, leaking, and consequent failure are known complications. The aim of this study was to evaluate continuous perineural catheter tip-to-nerve apposition in vivo over 48 hours comparing 2 different simple fixation strategies. METHODS: Subjects presenting for a continuous interscalene nerve block were randomized to perineural catheter fixation with 1 of 2 types of adhesive: Dermabond (2-octylcyanoacrylate) or Mastisol (alcohol 23A, gum mastic, storax, and methyl salicylate), covered with a simple transparent dressing. The primary outcome was the evaluation of catheter-to-nerve apposition maintenance over 48 hours via both a blinded ultrasound evaluation of local anesthetic distribution and a blinded clinical assessment. Secondary outcomes included leakage at the catheter site, pain scores, opioid consumption, catheter-to-skin migration at the insertion site, and patient satisfaction. RESULTS: Sixty-six subjects were recruited and randomized to compare adhesive group catheter tip-to-nerve apposition on postoperative day 2 (POD 2). Within the intention-to-treat cohort, a statistically significant decrease of perineural catheter tip-to-nerve apposition in the Mastisol group (64.7%) compared with the Dermabond group (90.6%) on POD 2 (odds ratios [OR] 0.19; 95% confidence interval [CI] 0.05-0.75; P = .012) was observed. Similar results were observed on POD 1 (OR 0.19; 95% CI 0.03-1.38; P = NS) and POD 2 (OR 0.14; 95% CI 0.02-0.97; P = .008) within the as-treated cohort. Catheter leakage (OR 67; 95% CI 7.3-589) and median catheter migration difference at the skin insertion site (2.0 cm; 95% CI 0.5-2.5) were also significantly greater in the Mastisol group than in the Dermabond group from POD 0 to POD 2 (P < .001). Median postoperative opioid consumption difference in morphine equivalents (3.2 mg; 95% CI - 9.0 to 14.2) was not significantly different between the Dermabond and the Mastisol groups through POD 2 (P = .542). CONCLUSIONS: Perineural catheter fixation with Dermabond in continuous interscalene nerve block improves maintenance of catheter-to-nerve apposition when compared with Mastisol.

Resurgence of Vaccine-Preventable Diseases in the United States: Anesthetic and Critical Care Implications.

Vaccine-preventable diseases (VPDs) such as measles and pertussis are becoming more common in the United States. This disturbing trend is driven by several factors, including the antivaccination movement, waning efficacy of certain vaccines, pathogen adaptation, and travel of individuals to and from areas where disease is endemic. The anesthesia-related manifestations of many VPDs involve airway complications, cardiovascular and respiratory compromise, and unusual neurologic and neuromuscular symptoms. In this article, we will review the presentation and management of 9 VPDs most relevant to anesthesiologists, intensivists, and other hospital-based clinicians: measles, mumps, rubella, pertussis, diphtheria, influenza, meningococcal disease, varicella, and poliomyelitis. Because many of the pathogens causing these diseases are spread by respiratory droplets and aerosols, appropriate transmission precautions, personal protective equipment, and immunizations necessary to protect clinicians and prevent nosocomial outbreaks are described.

A randomized crossover study comparing a novel needle guidance technology for simulated internal jugular vein cannulation.

BACKGROUND: Despite ultrasound guidance for central line placement, complications persist, as exact needle location is often difficult to confirm with standard two-dimension ultrasound. A novel real-time needle guidance technology has recently become available (eZono, Germany) that tracks the needle during insertion. This randomized, blinded, crossover study examined whether this needle guidance technology improved cannulation of a simulated internal jugular (IJ) vein in an ultrasound phantom. METHODS: One hundred physicians were randomized to place a standard needle in an ultrasound neck phantom with or without the needle guidance system. Video cameras were placed externally and within the lumens of the vessels to record needle location in real time. The primary outcome measured was the rate of posterior wall puncture. Secondary outcomes included number of carotid artery punctures, number of needle passes, final needle position, time to cannulation, and comfort level with this new technology. RESULTS: The incidence of posterior vessel wall puncture without and with needle guidance was 49 and 13%, respectively (P < 0.001, odds ratio [OR] = 7.33 [3.44 to 15.61]). The rate of carotid artery puncture was higher without needle navigation technology than with needle navigation 21 versus 2%, respectively (P = 0.001, OR = 12.97 [2.89 to 58.18]). Final needle tip position being located within the lumen of the IJ was 97% accurate with the navigation technology and 76% accurate with standard ultrasound (P < 0.001, OR = 10.42 [2.76 to 40.0]). Average time for successful vessel cannulation was 1.37 times longer without guidance technology. CONCLUSION: This real-time needle guidance technology (eZono) shows significant improvement in needle accuracy and cannulation time during simulated IJ vein puncture.

Reduced Length of Hospitalization in Primary Total Knee Arthroplasty Patients Using an Updated Enhanced Recovery After Orthopedic Surgery (ERAS) Pathway.

Decreasing hospital length of stay may attenuate costs associated with total knee arthroplasty. The purpose of this study was to determine if updates to an existing orthopedic enhanced recovery after surgery (ERAS) pathway would improve length of hospitalization. Clinical and demographic data were collected on 252 primary total knee arthroplasties between January 2012 and July 2013. Pre-updated and post-updated ERAS pathway cohorts were analyzed for length of stay, clinical outcomes, and re-admissions. The mean length of stay decreased from 76.6 hours to 56.1 hours after implementation of the evidence-based orthopedic enhanced recovery after surgery pathway (P<0.001). This improvement was possible without a concomitant increase in readmission rates.

Continuous ultrasound-guided adductor canal block for total knee arthroplasty: a randomized, double-blind trial.

BACKGROUND: Adductor canal blocks have shown promise in reducing postoperative pain in total knee arthroplasty patients. No randomized, controlled studies, however, evaluate the opioid-sparing benefits of a continuous 0.2% ropivacaine infusion at the adductor canal. We hypothesized that a continuous adductor canal block would decrease postoperative opioid consumption. METHODS: Eighty subjects presenting for primary unilateral total knee arthroplasty were randomized to receive either a continuous ultrasound-guided adductor canal block with 0.2% ropivacaine or a sham catheter. All subjects received a preoperative single-injection femoral nerve block with spinal anesthesia as is standard of care at our institution. Cumulative IV morphine consumption 48 hours after surgery was evaluated with analysis of covariance, adjusted for baseline characteristics. Secondary outcomes included resting pain scores (numeric rating scale), peak pain scores during physical therapy on postoperative days 1 and 2, quadriceps maximum voluntary isometric contraction, distance ambulated during physical therapy, postoperative nausea and vomiting, and satisfaction with analgesia. RESULTS: Eighty subjects were randomized, and 76 completed the study per-protocol. The least-square mean difference in cumulative morphine consumption over 48 hours (block-sham) was--16.68 mg (95% confidence interval, -29.78 to -3.59, P = 0.013). Total morphine use between 24 and 48 hours (after predicted femoral nerve block resolution) also differed by least-square mean -11.17 mg (95% confidence interval,: -19.93 to -2.42, P = 0.013). Intention-to-treat analysis was similar to the per-protocol results. Functional outcomes revealed subjects in the adductor canal catheter group had better quadriceps strength (P = 0.010) and further distance ambulated (P = 0.034) on postoperative day 2. CONCLUSIONS: A continuous adductor canal block for total knee arthroplasty reduces opioid consumption compared with that of placebo in the first 48 hours after surgery. Other outcomes including quadriceps strength, distance ambulated, and pain scores all show benefit from an adductor canal catheter after total knee arthroplasty but require further study before being interpreted as conclusive.

Delayed quadriceps weakness after continuous adductor canal block for total knee arthroplasty: a case report.

Adductor canal catheters have been shown to improve analgesia while maintaining quadriceps strength after total knee arthroplasty. We describe a patient who underwent total knee arthroplasty that likely had delayed quadriceps weakness as a result of a standard continuous 0.2% ropivacaine infusion at 8 ml/h within the adductor canal. On the day of surgery, the patient was able to stand and ambulate with minimal assistance. On the first post-operative day after surgery, approximately 20 h after starting the ropivacaine infusion, profound weakness of the quadriceps was noted with no ability to stand. Contrast subsequently injected through the adductor canal catheter under fluoroscopy revealed proximal spread approaching the common femoral nerve with as little as 2 ml of volume. This rare case of profound quadriceps weakness after a continuous adductor canal block reveals that local anaesthetic at the adductor canal can spread in a retrograde fashion towards the common femoral nerve, potentially resulting in quadriceps weakness.

Ultrasound-guided adductor canal block for arthroscopic medial meniscectomy: a randomized, double-blind trial.

PURPOSE: The saphenous nerve block using a landmark-based approach has shown promise in reducing postoperative pain in patients undergoing arthroscopic medial meniscectomy. We hypothesized that performing an ultrasound-guided adductor canal saphenous block as part of a multimodal analgesic regimen would result in improved analgesia after arthroscopic medial meniscectomy. METHODS: Fifty patients presenting for ambulatory arthroscopic medial meniscectomy under general anesthesia were prospectively randomized to receive an ultrasound-guided adductor canal block with 0.5% ropivacaine or a sham subcutaneous injection of sterile saline. Our primary outcome was resting pain scores (numerical rating scale; NRS) upon arrival to the postanesthesia care unit (PACU). Secondary outcomes included NRS at six hours, 12 hr, 18 hr, and 24 hr; postoperative nausea; and postoperative opioid consumption. RESULTS: There was a statistically significant difference in mean NRS pain scores upon arrival to the PACU (P = 0.03): block group NRS = 1.71 (95% confidence interval [CI] 0.73 to 2.68) vs sham group NRS = 3.25 (95% CI 2.27 to 4.23). Cumulative opioid consumption (represented in oral morphine equivalents) over 24 hr was 71.8 mg (95% CI 56.5 to 87.2) in the sham group vs 44.9 mg (95% CI 29.5 to 60.2) in the block group (P = 0.016). CONCLUSIONS: An ultrasound-guided block at the adductor canal as part of a combined multimodal analgesic regimen significantly reduces resting pain scores in the PACU following arthroscopic medial meniscectomy. Furthermore, 24-hr postoperative opioid consumption and pain scores were also reduced.

Comparing bupivacaine alone to liposomal bupivacaine plus bupivacaine in interscalene blocks for total shoulder arthroplasty: a randomized, non-inferiority trial.

INTRODUCTION: Interscalene brachial plexus blocks are a commonly performed procedure to reduce pain following total shoulder arthroplasty. Liposomal bupivacaine has been purported to prolong the duration of brachial plexus blocks for up to 72 hours; however, there has been controversy surrounding the analgesic benefits of this drug. Our hypothesis was that an interscalene block performed with bupivacaine alone would be non-inferior to a combination of liposomal bupivacaine and bupivacaine with respect to opioid consumption following total shoulder arthroplasty. METHODS: Subjects presenting for primary total shoulder arthroplasty were randomized in a 1:1 ratio to an ultrasound-guided, single-injection interscalene block with either a combination of liposomal bupivacaine and bupivacaine (LB group) or bupivacaine without additive (Bupi group). The primary outcome of this study was 72-hour postoperative cumulative opioid consumption (in oral morphine equivalents) with a non-inferiority margin of 22.5 mg. Secondary outcomes included pain scores, patient satisfaction with analgesia and patient reported duration of sensory block. RESULTS: Seventy-six subjects, 38 from the Bupi group and 38 from the LB group, completed the study. Analysis of the primary outcome showed a 72-hour cumulative geometric mean oral morphine equivalent consumption difference of 11.9 mg (95% CI -6.9 to 30.8) between groups (calculated on the log scale). This difference constitutes approximately 1.5 tablets of oxycodone over 3 days. No secondary outcomes showed meaningful differences between groups. DISCUSSION: Interscalene brachial plexus blocks performed with bupivacaine alone did not demonstrate non-inferiority compared to a mixture of liposomal bupivacaine plus bupivacaine with regards to 72-hour cumulative opioid consumption following total shoulder arthroplasty. However, the difference between groups did not appear to be clinically meaningful.

Use of epidurography in the perioperative and acute pain setting.

Ensuring proper placement of epidural catheters is critical to improving their reliability for pain control and maintaining confidence in their continued use. This article will seek to address the role of objective confirmation of successful epidural placement via either single view or continuous epidural contrast studies, each creating an 'epidurogram.' Furthermore, the pertinent anatomical corollaries of continuous fluoroscopy used frequently in chronic pain medicine, from which these techniques emerged, will be addressed. Technical radiographic information needed to better understand and troubleshoot these studies is also included. Image examples which highlight the patterns key for successful interpretation of epidurograms will be provided. The aim of this paper was to provide an anesthesiologist unfamiliar with fluoroscopic evaluation of epidural catheters with the tools necessary to successfully conduct and interpret such an examination.

Feasibility and efficacy of cryoneurolysis analgesia in robotic-assisted thoracoscopic surgery (CARTS): a pilot study.

Opioid therapy has been the mainstay therapy of post-operative pain management in thoracic surgery patients. With the high incidence of chronic pain in thoracic surgery patients and adverse effects of opioids, we examined the safety and efficacy of cryoneurolysis as an adjunct for narcotic-free pain management in robotic-assisted thoracoscopic lobectomies. Ten consecutive patients undergoing robotic-assisted (DaVinci) pulmonary resection and cryoneurolysis were compared to ten patients managed without intraoperative cryoneurolysis. All patients received multimodal pain regimen including paravertebral blocks as per our institutional enhanced recovery pathway. Patients with chronic pain and chronic opioid use were excluded. We compared inpatient and outpatient opioid consumption measured in morphine equivalents (mme), incidence of opioid-free outpatient recovery, and adverse events. The two groups did not differ significantly in terms of baseline demographics. Both inpatient (88.13 vs 26.92 mme) and outpatient (118.5 vs 34.5 mme) use of narcotics were significantly lower in the cryoneurolysis group (p < 0.05) with seven of ten patients receiving cryoneurolysis able to recover without the use of opioids in the outpatient setting, compared to two in the control group. One patient reported post-operative neuralgia in each cryoneurolysis and control group. There were no readmissions in either group and mean length of stay was identical at 1.7 days in control group and 1.1 days in experimental group (p = 0.33). The use of intraoperative intercostal cryoneurolysis may safely reduce the utilization of outpatient opioids in patients undergoing robotic-assisted thoracoscopic surgery. A randomized controlled trial is warranted to validate these findings in a larger cohort of patients.

Pericapsular nerve group (PENG) block for hip arthroscopy: a randomized, double-blinded, placebo-controlled trial.

INTRODUCTION: Arthroscopic hip surgery is associated with significant postoperative pain. Femoral nerve blocks have been shown to improve postoperative analgesia at the expense of quadriceps weakness. The pericapsular nerve group (PENG) block could be an alternative that may improve postoperative analgesia while preserving quadriceps strength. Our hypothesis was that a PENG block would provide superior postoperative analgesia compared with a sham block following arthroscopic hip surgery. METHODS: Subjects presenting for arthroscopic hip surgery were randomized in a 1:1 ratio to either an ultrasound-guided unilateral, single-injection PENG block (PENG group) with 20 mL of 0.5% ropivacaine or a sham injection with 5 mL of 0.9% normal saline (Sham group) prior to receiving general anesthesia. The primary outcome of this study was worst pain score within 30 min of emergence from anesthesia. Secondary outcomes included opioid consumption, patient satisfaction with analgesia, opioid-related adverse events, and persistent opioid use at 1 week. RESULTS: Sixty-eight subjects, 34 from the PENG group and 34 from the Sham group, completed the study per protocol. Analysis of the primary outcome demonstrated a mean difference in pain scores of -0.79 (95% CI -1.96 to 0.37; p=0.17) between the PENG and Sham groups immediately following surgery. No secondary outcomes showed statistically significant differences between groups. DISCUSSION: This study demonstrates that a preoperative PENG block does not improve analgesia following arthroscopic hip surgery. TRIAL REIGSTRATION NUMBER: NCT04508504.

Opioid-Limiting Pain Control After Transurethral Resection of the Prostate: A Randomized Controlled Trial.

OBJECTIVE: To assess whether a multimodal opioid-limiting protocol and patient education intervention can reduce postoperative opioid use following transurethral resection of the prostate. METHODS: This prospective, non-blinded, single-institution, randomized controlled trial (NCT04102566) assigned 50 patients undergoing a transurethral resection of the prostate to either a standard of care control (SOC) or multimodal experimental group (MMG). The intervention included adding ibuprofen to the postoperative pain regimen, promoting appropriate opioid use while hospitalized, an educational intervention, and discharging without opioid prescription. Data regarding demographics, operative data, opioid use, pain scores, and patient satisfaction were compared. RESULTS: A total of 47 patients were included, n = 23 (MMG) and n = 24 (SOC). Demographic and operative findings were similar. Statistical analysis for noninferiority demonstrated non-inferior inpatient pain control (mean pain score 2.5 MMG vs 2.4 SOC, P = 0.0003). The multimodal group used significantly fewer morphine milligram equivalents after discharge (0 vs 4.1, P = 0.04). Inpatient use was reduced but did not reach statistical significance (6.0 vs 9.8, P = 0.2). Mean satisfaction scores with pain control were similar (9.6 MMG vs 9.2 SOC, P = 0.32). No opioid prescriptions were requested after discharge. Adverse events and medication side effects were infrequent and largely similar between groups. CONCLUSION: Implementation of an opioid-limiting postoperative pain protocol and patient education resulted in no outpatient opioid use while maintaining patient satisfaction with pain control. Eliminating opioids following a common urologic procedure will decrease risk of opioid-related adverse events and have a positive downstream impact.